PROJECT SUMMARY: Background: Colorectal cancer screening (CRCS) saves lives, but screening rates remain low, especially among ethnic minorities and others who get medical care in safety net clinical settings. In these settings the primary CRCS option for average risk patients is annual home fecal occult blood testing (FOBT), a test that has been shown in several studies to reduce colorectal cancer mortality. Offering FOBT during nurse-run annual influenza vaccination clinics at San Francisco General Hospital has been shown to increase CRCS rates. Specific Aims: We propose to (1) adapt the "FLU-FOBT Program" for primary care clinics that provide influenza vaccines but do not run dedicated annual influenza clinics;(2) study the efficacy of the adapted "FLU- FOBT Program" in safety net primary care clinics;(3) study its robustness as a practical intervention to increase CRCS in these settings, and (4) develop tools and materials for dissemination of the adapted FLU- FOBT Program as a practical approach to reduce CRCS disparities in other clinical settings in the safety net. Methods: In Phase 1 (Year 1), we will adapt the FLU-FOBT Program as a primary care intervention at Chinatown Public Health Clinic (CPHC) in San Francisco. The CPHC nursing staff will offer influenza vaccination to all adults over age 50 who present for primary care during the 2008-9 influenza vaccination season. Patients who accept influenza vaccine will be assessed for CRCS eligibility and offered FOBT by the nurse if due. In Phase 2 (Year 2), we will determine the efficacy of this intervention in a time-randomized trial in 6 other safety net primary care clinics in San Francisco that serve a diverse, multi-ethnic population. The intervention will consist of exposure to the FLU-FOBT Program, and the comparison group will be usual care in which influenza vaccination will be offered without CRCS. The primary outcome will be the proportion of primary care clinic attendees who are initially due for CRCS and become up to date after the intervention, within the intervention and usual care arms of the study. The robustness of the FLUFOBT Program as a practical intervention for "real world" clinical settings will be determined using the RE-AIM criteria (reach, effectiveness, adoption, implementation, maintenance). In Phase 3 (Year 3), we will complete the analyses of efficacy and robustness and develop tools for further dissemination and implementation to other primary care settings where FOBT remains the primary screening strategy for average risk adults. Public Health Relevance: If successful and widely disseminated, the "FLU-FOBT Program" could increase access to CRCS for millions of Americans. More generally, this research could serve as a model strategy to develop, translate, and implement an evidence-based intervention to promote health and prevent disease in primary care settings where health disparities persist.